Provider Demographics
NPI:1497998512
Name:EWALT, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:EWALT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1275 YORK AVENUE
Mailing Address - Street 2:DEPT OF PATHOLOGY, BOX #36
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065
Mailing Address - Country:US
Mailing Address - Phone:212-639-8137
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVENUE
Practice Address - Street 2:DEPT OF PATHOLOGY, BOX #36
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065
Practice Address - Country:US
Practice Address - Phone:212-639-8137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0058760207ZC0500X, 207ZH0000X, 207ZP0007X
CAA121762207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology